Ministry of Health and Family Welfare Government of India UTTAR PRADESH DISTRICT LEVEL HOUSEHOLD AND FACILITY SURVEY ( ) Facility-Survey

Transcription

1 DLHS-4 Ministry of Health and Family Welfare Government of India UTTAR PRADESH DISTRICT LEVEL HOUSEHOLD AND FACILITY SURVEY (22-) Facility-Survey International Institute for Population Sciences (Deemed University) Mumbai

2 INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES Vision: To position IIPS as a premier teaching and research institution in population sciences responsive to emerging national and global needs based on values of inclusion, sensitivity and rights protection. Mission: The Institute will strive to be a centre of excellence on population, health and development issues through high quality education, teaching and research. This will be achieved by (a) creating competent professionals, (b) generating and disseminating scientific knowledge and evidence, (c) collaboration and exchange of knowledge, and (d) advocacy and awareness. 2

3 Ministry of Health and Family Welfare, District Level Household and Facility Survey 22- Uttar Pradesh International Institute for Population Sciences (Deemed University) Mumbai

4 Suggested citation:- International Institute for Population Sciences (IIPS), 24. District Level Household and Facility Survey (DLHS-4), 22-: India. Uttar Pradesh: Mumbai: IIPS. For additional information, please contact: Director/Project Coordinator (DLHS-4) International Institute for Population Sciences Govandi Station Road, Deonar Mumbai (India) Telephone: /5/6, , Fax: , rchpro@iips.net, director@iips.net Website: Additional Director General (Stat.) Ministry of Health and Family Welfare Government of India Nirman Bhavan New Delhi 1 1 Telephone: Fax: adg-mohfw@nic.in Chief Director (Stat.) Ministry of Health and Family Welfare Government of India Nirman Bhavan New Delhi 1 1 Telephone: Fax: cdstat@nic.in Website: http: // 4

5 CONTRIBUTORS F. Ram L. Ladu Singh B. Paswan S. K. Singh H. Lhungdim T. V. Sekher K. M. Ponnapalli Chander Shekhar Manoj Alagarajan EHI International Pvt. Ltd. V. K. Malhotra A. H. Fatmi 5

6 CONTENTS PAGE 1. INTRODUCTION OBJECTIVES METHODOLOGY DATA COLLECTION TOOLS & TECHNIQUE DEMOGRAPHIC BACKGROUND OF UTTAR PRADESH SUB- HEALTH CENTRE PRIMARY HEALTH CENTRE COMMUNITY HEALTH CENTRE SUB-DIVISIONAL HOSPITAL DISTRICT HOSPITAL TABLES APPENDIX

7 LIST OF TABLES PAGE Table 1.1 Average population covered by health facility by districts Table 1.2 Status of infrastructure at Sub-Health Centre functioning in government building by districts Table 1.3 Percentage of Sub-Health Centres having different activities by districts Table 1.4 Available human resources at Sub Health Centres by districts Table 2.1 Available human resources at Primary Health Centres by districts Table 2.2 Available infrastructure at Primary Health Centres by districts Table 2.3 Specific health facilities available at Primary Health Centres by districts Table 2.4 Number of Primary Health Centres having different activities by districts Table 3.1 Human resources available at Community Health Centres by districts Table 3.2 Specific health care facilities available at Community Health Centres by districts Table 3.3 Number of Community Health Centres having different activities by districts Table 4.1 Human resources & other services available at Divisional Hospitals by districts

8 LIST OF FIGURES PAGE Figure 1 Sub health Centres where citizen charter displayed by districts Figure 2 Sub Health Centres with VHSC facilitated by dstricts Figure 3 Sub health Centres received untied fund by districts 28 Figure 4 PHCs having Lady Medical Officer. 30 Figure 5 PHCs having at least 4 beds 32 Figure 6 PHCs having referral services 32 Figure 7 PHCs conducted at least deliveries 33 Figure 8 CHCs having normal deliveries services districts 36 Figure 9 CHCs having new born care services on 24x7 hour basis by districts 36 8

9 ACRONYMS AFMC AHS AIDS ANC ANM ARI ASHA AWW AYUSH BCG BP BPL CAB CAPI CHC CPR DBS DH DLHS DPT EAG ECG ECP ELISA EPI FA FBS FHW FRU FOD FP FS FSU GPS GoI HH HIV ICDS ICTC IEC IFA IIPS IMNCI IMR IPHS IUD JSY LMO LPG MCEB MDG MMR MO MoHFW MoU Administrative and Financial Management Committee Annual Health Survey Acquired Immune Deficiency Syndrome Antenatal Care Auxiliary Nurse Midwife Acute Respiratory Infection Accredited Social Health Activist Anganwadi Worker Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Bacillus Calmette Guerin Blood Pressure Below Poverty Line Clinical Anthropometric Biochemical (Test) Computer Assisted Personnal Interviewing Community Health Centre Contraceptive Prevalence Rate Dried Blood Spot District Hospital District Level Household and Facility Survey Diphtheria, Pertussis and Tetanus Empowered Action Group Electrocardiogram Emergency Contraceptive Pill Enzyme-linked Immunosorbent Assay Expanded Programme on Immunization Field Agency Fasting Blood Sugar Female Health Worker First Referral Unit Field Operation Division Family Planning Female Sterilization First Stage Unit Global Positioning System Government of India Household Human Immune Deficiency Virus Integrated Child Development Scheme Integrated Counseling and Testing Centre Information, Education and Communication Iron and Folic Acid International Institute for Population Sciences Integrated Management of Neonatal and Childhood Illnesses Infant Mortality Rate Indian Public Health Standards Intra-uterine Device Janani Suraksha Yojana Lady Medical Officer Liquefied Petroleum Gas Mean Children Ever Born Millennium Development Goal Maternal Mortality Ratio Medical Officer Ministry of Health and Family Welfare Memorandum of Understanding 9

10 ACRONYMS MoA MTP NC NIC NIHFW NGO NPP NRHM NSSO NSV OBC OPD ORS ORT OT PHC PI PNC PRC PPS PSU RCH RKS RTI SDH SDRD SC SHC ST STI TBA TAC TOT TT T.V. UFS UFWC UHP UIP UNFPA UNICEF USU UT VCTC VHSNC WHO Memorandum of Agreement Medical Termination of Pregnancy Natal Care National Informatics Centre National Institute of Health and Family Welfare Non-Governmental Organization National Population Policy National Rural Health Mission National Sample Survey Organization Non-scalpel Vasectomy Other Backward Classes Out-Patient Department Oral Re-hydration Salt Oral Re-hydration Therapy Operation Theatre Primary Health Centre Partner Institute Post-Natal Care Population Research Centre Probability Proportional to Size Primary Sampling Unit Reproductive and Child Health Rogi Kalyan Samiti Reproductive Tract Infection Sub-Divisional Hospital Survey Design and Research Division Scheduled Caste Sub-Health Centre Scheduled Tribe Sexually Transmitted Infection Trained Birth Attendant Technical Advisory Committee Training of Trainers Tetanus Toxoid Television Urban Frame Survey Urban Family Welfare Centre Urban Health Post Universal Immunization Programme United Nations Population Fund United Nations Children's Fund Ultimate Sampling Unit Union Territory Voluntary Counseling and Testing Centre Village Health, Sanitation and Nutrition Committee World Health Organization

11 Preface and Acknowledgements The District Level Household and Facility Survey-4 (DLHS-4) is a nationwide survey covering 640 districts from 36 States and Union Territories of India. This is the fourth round of the district level household survey which was conducted during 22-. The Survey was funded by the Ministry of Health and Family Welfare, Government of India. At the outset we acknowledge our sincere gratitude to the Ministry of Health & Family Welfare, Government of India for designating the International Institute for Population Sciences (IIPS) as the Nodal Agency for conducting District Level Household and Facility Survey-4 (DLHS-4). We would also like to take this opportunity to acknowledge Shri Bhanu Pratap Sharma, Secretary-Ministry of Health and Family Welfare (MoHFW), Government of India for his advice, suggestions and support. Our special thanks are due to Shri Lov Verma and Shri Keshav Desiraju former Secretaries, Ministry of Health and Family Welfare (MoHFW), Government of India, for providing overall guidance and support extended to the project. We gratefully acknowledge the active involvement, assistance, help, co-operation and suggestions received time to time from Shri C.R.K. Nair, the Additional Director General, Dr. Rattan Chand, the Chief Director and Shri Biswajit Das, the Director-Statistics Division, Ministry of Health and Family Welfare, Government of India. We also extend our thanks to Smt. Madhu Bala, former Additional Director General and Shri Rajesh Bhatia, former Director-Statistics Division, Ministry of Health and Family Welfare, Government of India for their support. Our special thanks are to all the members of Technical Advisory Committee of DLHS- 4, particularly Dr. N. S. Sastry, Chairman, Former DG & CEO (NSSO), for their constant involvement and technical inputs and support at various stages of the survey. We also gratefully acknowledge all members of Sub-Committee on Sampling especially Shri G. C. Manna, Chairman, DDG, CSO, MoSPI, for their technical support from time to time. Thanks are also due to Dr. Rajiv Mehta and Shri A. K. Mehra former Additional Director Generals at the National Sample Survey Organization, Kolkata for providing UFS blocks. This acknowledgement cannot be concluded without expressing appreciation for the efforts and hard work put in by the field investigators, supervisors, health investigators in collecting data and timely transferring data to IIPS. Last but not the least, we are grateful and appreciate the efforts of all the officials who participated and spared their valuable time with us by providing the required information. DLHS-4 Coordinators International Institute for Population Sciences

12 KEY- Indicators Number/Percentage Indicators DLHS-4 DLHS-3 Health Facilities covered Number of Sub-Health Centres 2,595 2,4 Number of Primary Health Centres (PHC) 1,1 819 Number of Community Health Centres (CHC) including Block PHCs Number of Sub-Divisional Hospitals (SDH) NA Number of District Hospitals (DH) 2 84 Availability of Health Infrastructure, Staff and Services at (%) Sub-Health Centre Sub-Health Centre located in government building Sub-Health Centre with ANM Sub-Health Centre with male health worker Sub-Health Centre with ANM residing in staff quarter where facility is available Sub-Health Centre with additional ANM available Primary Health Centre (PHC) PHCs functioning on 24 X 7 hours basis PHCs having Lady Medical Officer * PHCs with at least 4 beds PHCs with AYUSH doctor * PHCs having residential quarter for Medical Officer PHCs having new-born care services on 24 X 7 hours basis PHCs having referral services for pregnancies/delivery on 24 X 7 hours basis PHCs conducted at least deliveries during last one month on 24 X 7 hours basis Community Health Centre (CHC) CHCs having 24 X 7 hours normal delivery services CHCs having Obstetrician/Gynaecologist CHCs having Anaesthetist.1 NA CHCs having functional Operation Theatre CHCs designated as FRUs CHCs designated as FRUs offering caesarean section CHCs having new born care services on 24 X 7 hours basis Sub Divisional Hospital (SDH) SDHs having Paediatrician 5 NA SDHs having regular Radiographer 1 NA SDHs having 2D Echo facility NA SDHs having Ultrasound facility NA SDHs having three phase connection 9 NA SDHs having critical care area 6 NA SDHs having Suggestion and Complaint Box 6 NA District Hospital (DH) DHs having Paediatrician DHs having regular Radiographer DHs having 2D Echo facility DHs having Ultrasound facility 69.7 NA DHs having three phase connection DHs having critical care area DHs having Suggestion and Complaint Box * Out of total medical officers

13 1. INTRODUCTION India is a signatory to the Alma Ata Declaration of 1978 and had committed to attaining Health for All by 20AD through the Primary Health Care approach. The establishment of Primary Health Centres in India started as early as in 1952, and over the last six decades it has undergone several changes to meet the increasing demand for health care services. Until the eleventh Five Year Plan, the emphasis was on the expansion of the health care establishment. However, during the Eighth and subsequent plans the emphasis was mainly on consolidation of existing health infrastructure rather than on expansion. The thrust has been on qualitative improvement in the health services through strengthening of physical facilities like provision of essential equipment, supply of essential drugs and consumables, construction of buildings and staff quarters, filling up of vacant posts of medical and paramedical staff and in-service training of staff. The National Health Policy stressed on the provision of preventive, promotive and rehabilitative health services to the people thereby making a shift from medical care to health care. The delivery of Primary Health Care is the foundation of the rural health care system and is an integral part of the national health care system. In the rural areas, services are provided through a network of integrated health and family welfare system and the health programmes have been restructured and reoriented from time to time to meet the objectives of the National Health Policy. The health care delivery system in India can be grouped into four types: (a) public sector, including Government runs hospitals, dispensaries and health centres, (b) those run by non- governmental organizations (NGOs), (c) organized private sector and (d) informal private sector comprising faith healers and herbalists etc. Studies have shown that the Government is by far the dominant source of health care such as immunization, antenatal care, family planning services, and infectious disease control. The number of different facilities varies from district to district due to the differences in the population in each district as well as due to the differences in adherence to population norms. The population norms for some of the facilities are given below Three rounds of District Level Household and Facility Surveys (DLHS) have been undertaken in the past (Round- I in , Round-II in 20-, and Round-III in 27- ) with the main objective to provide reproductive and child health database at district level in India. The data from these surveys have been useful in setting the benchmarks and examining the progress the country has made after the implementation of RCH Programmes. These surveys were useful for the central and state governments in evaluation, monitoring and planning strategies. In view of the completion of six years of National Rural Health Mission (25-), there is a felt need to focus on the achievements and improvements so far. It is, therefore, proposed to conduct DLHS-4.

14 Along with the Household Survey, Facility Survey is also carried out. Facility Survey will provide information on the availability and utilization of services at District Hospital (DH), Sub-divisional hospital (SDH), Community Health Centre (CHC), Primary Health Centre (PHC) and Sub Health Centre (SHC). India s Public Health System is a three tier system namely Primary, Secondary and Tertiary levels of health care, which aims to develop as well as deliver health care services to the individuals and communities in the country. Primary Health Care provides preventive, curative and promotive services to the community, in which only common and simple ailments are taken care of at this level. Primary Health Centres and Sub Health Centres form the Primary Health Care. Secondary Health Care is meant to provide curative and specialized care to the community and works as first referral centre for PHCs and Sub Health Centres. Community Health Centres, Sub- Divisional Hospitals, District-Hospitals function as secondary level of health care. Tertiary Health Care provides super specialized as well as comprehensive health care services to the community for complex ailments. Medical colleges and apex health centres function as tertiary health care. Primary Health Care Secondary Health Care Tertiary Health Sub- Health Centre Community Health Centre Medical College Primary Health Centre District Hospital/Sub-Divisional Hospital Apex Centre Every district is expected to have a District Hospital linked with other public hospitals and health centres down below the district such as Sub-district/Sub-divisional Hospitals, Community Health Centres, Primary Health a and Sub Health Centres. Centre Population Norm Plain areas Hilly/Tribal area Sub-Centre 5,0 3,0 PHC 30,0 20,0 CHC 0,0 80,0 Sub-Centres are peripheral contact points between the Primary Health Care system and the community. One male Multipurpose Worker and one female Multipurpose Worker/ANM are expected to be appointed at each facility. A PHC, on the other hand, is the first contact point between the village community and the Medical Officer. A PHC is expected to have a Medical Officer and paramedical and other staff. It acts as a referral unit for 5 to 6 Sub-Centres. It should have 4 to 6 beds for patients. The activities of the PHCs involve curative, preventive, promotive and family welfare services.

15 National Rural Health Mission (NRHM) Recognizing the importance of health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has launched the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health, via nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian Systems of Medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalizing community health Centres into functional hospitals in compliance with the Indian Public Health Standards of the country. The goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children. Vision of NRHM The National Rural Health Mission (25-) seeks to provide effective healthcare to rural population throughout the country with special focus on states, which have weak public health indicators and/or weak infrastructure. The Mission is an articulation of the commitment of the government to raise public spending on health from 0.9% of GDP to 2-3% of GDP It aims to undertake architectural correction of the health system to enable it to effectively handle increased allocations as promised under the National Common Minimum Programme and promote policies that strengthen public health management and service delivery in the country. It has as its key components provision of a female health activist in each village; a village health plan prepared through a local team headed by the Health & Sanitation Committee of the Panchayat; strengthening of the rural hospital for effective curative care and made measurable and accountable to the community through Indian Public Health Standards (IPHS); and integration of vertical Health & Family Welfare Programmes and Funds for optimal utilization of funds and infrastructure and strengthening delivery of primary healthcare. It seeks to revitalize local health traditions and mainstream AYUSH into the public health system.

16 It aims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health. It seeks decentralization of programmes for district management of health. It seeks to address the inter-state and inter-district disparities, especially among the high focus states, including unmet needs for public health infrastructure. It shall define time-bound goals and report publicly on their progress. It seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare. NRHM Goals 1. Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR). 2. Universal access to public health services such as women s health, child health, water, sanitation, hygiene, immunization, and nutrition. 3. Prevention and control of communicable and non-communicable diseases, including locally endemic diseases. 4. Access to integrated comprehensive primary healthcare. 5. Population stabilization, gender and demographic balance. 6. Revitalize local health traditions and mainstream AYUSH. 7. Promotion of healthy life styles. Reproductive and Child Health Programme (RCH) Reproductive and Child Health Programme is a national health programme aiming at improving the health status of women and children. RCH is an integrated for the approach in implementation of family welfare programme, oral rehydration therapy, child survival & safe motherhood programme, acute respiratory infection control Programme, etc at field level, which not only cut the overlapping expenditure but also optimizes the outcome at field level. Reproductive and Child Health Programme has the following components. 1. Maternal and Child health 2. Family Welfare 3. Client Approach Health Care 4. Prevention /Management of RTI/STD/AIDS All the maternal and child health interventions and fertility regulation services have been delivered through RCH programmes. Important interventions of RCH Programme include Immunization, Vitamin A prophylaxis, Oral Rehydration Therapy, Prevention of death due to pneumonia, Antenatal checkups, Safe delivery, Anaemia control Programme for safe motherhood, etc. In addition in some districts the programmes include screening and treatment of RTI/ STI/HIV. Essential Obstetric Care (EOC) implemented to provide basic

17 maternity services to all pregnant women such as early registration of pregnancy (within to weeks), minimum three antenatal checkups by ANM and Medical Officer, safe delivery at home, institutional delivery and three postnatal checkups. On the other hand, emergency obstetric care (EMOC) services will deal with complications arising during pregnancy and new born care by setting up first referral unit (FRU) at Sub-District level on a 24x7 basis. 2. OBJECTIVES The primary objective of the facility survey is to assess district health care system in terms of appropriateness, comprehensiveness, adequacy, availability, accessibility and affordability of MCH and RCH services at various government health facilities. The facility survey will focus on supply of critical materials / inputs of MCH and RCH project, man power availability and availability of services at the DH (District Hospital), SDH (Sub-Divisional Hospital), CHC (Community Health Centre), PHC (Primary Health Centre) and SHC (Sub- Health Centre), DLHS-4 would make efforts to link the data from household and facility surveys. 3. METHODOLOGY The PSU list was provided by RGI, which has been used in the Annual Health Survey (AHS) for conducting household survey in EAG states including Assam. After systematic up-gradation of that list with separate district wise PSU list prepared for each EAG state and same has been provided to the field agencies to conduct the facility survey. Another important component of DLHS-4 is the Facility Survey (FS) in which information on various aspects related to facilities will be collected from different officials/departments of health facilities such as Sub Health Centre, Primary Health Centre (PHC), Community Health Centre (CHC), Sub-Divisional Hospital (SDH), and District Hospital (DH) in each district, to understand their coverage as well as services provided. It is, therefore, essential to identify the link health facilities that serve the selected PSU. Mapping and listing team will collect the names of such Sub Health Centre and PHC of the selected rural PSU at the time of mapping and listing operation and record them in the format provided. Along with this, the mapping and listing team will also collect the entire list of the CHC and SDH and DH of the concerned district. The selected village (PSU) will be under the jurisdiction of one of the Sub Health Centres and that Sub Health Centre will be identified and covered in the survey. Subsequently, the next higher facility, i.e. the PHC, which caters to the Sub Health centre will also be covered in the survey. All CHCs, SDHs and DH within the district will be covered in facility survey. For the identification of the SHC and PHC of each selected PSU, one has to approach Chief Medical Officer's office and obtain the list for the same and verify the jurisdiction of the SHC and PHC from the village Sarpanch. In some cases, DH may be attached to a teaching facility, and in that case the DH has to be identified but the facilities related to teaching are not be covered. In case a district has two District Hospitals, then both the DHs will be surveyed.

18 Identification & coding of health facility will be done based on the list provided by the mapping listing team. After preparing the list, a copy will be provided to the supervisor and health investigators (HIs) of the district. The same list will be entered in excel sheet by FA and should be sent to IIPS along with the list of PSUs. While assigning code to a specific health facility, ensure that the correct code is entered for each health facility as given in the obtained list with the supervisor. 4. DATA COLLECTION TOOLS AND TECHNIQUES (a) Questionnaires, Training and Field Work There are four types of questionnaires that were prepared (see Appendix A) and canvassed for Facility Survey. One questionnaire each was for District Hospital/Sub Divisional Hospital, Community Health Centre, Primary Health Centres, Sub Health Centres. The overall content of the questionnaire and the format was discussed at length among the coordinators of the RCH Project at IIPS before it was presented to the RCH Technical Advisory Committee (TAC) for a formal discussion. At every stage of the preparation of the questionnaire, the officials of the Ministry of Health and Family Welfare were involved. The questionnaires that were finalized after the detailed discussion with the TAC were sent to the MoHFW for their final approval. After obtaining the clearance from the Ministry, the questionnaires were discussed at length in a training-cum-workshop organized by IIPS. The Workshop was attended by representatives of all the Field Agencies - EHI International, Gurgaon; Indian Institute of Health Management Research, Jaipur; AMS Lucknow, Centre for Operations Research Training, Vadodara; Vimarsh, Gurgaon; Sigma, New Delhi. A MoHFW and NIHFW representative, a resource person and a member of the Technical Advisory Committee participated actively in the discussion of questionnaires. After the training of trainers organized by IIPS, each Field Agency gave training to the investigators in their respective areas followed by visits to different levels of health care establishments as part of the training. The actual survey was completed in 22-. In the facility survey, the information collected at the SHC level were availability of the human resources, physical infrastructure, equipment and essential drugs and MCH service provided in one month preceding the survey. From the PHC, status of availability for 24x7 facility and services for delivery and newborn care were also collected. In addition the additional information collected at the PHC level were the availability of Lady Medical Officer, functional Labour Room, Operation Theatre, sufficient number of beds, drug storage facilities, waiting room for OPD, availability of RCH related equipment, essential drugs and essential laboratory testing facilities. The Information that were collected for the Community Health Centre (CHC) included availability of 24X7 services for delivery and new born care, status of in-position clinical, supporting and Para-medical staff, availability of specialists trained for NSV (Non-Scalpel Vasectomy), emergency obstetric, MTP, new born care, treatment of RTI / STI, IMNCI, ECG etc. The physical infrastructure of the CHC was such that there was water supply, electricity, communication; waste disposal

19 facilities, OT, Labour Room and availability of residential quarters for medical doctors were also recorded in terms of the facility survey. It was from the Sub-Divisional and District Hospitals that the status of the availability of essential laboratory and ambulance services, emergency obstetric care service, availability of specialists, nurses, paramedics and technicians either on regular or contractual basis were collected. In addition to the infrastructure, the provision for the bio-medical and waste disposal and availability of residential quarters for doctors, nurses and staff were also recorded. The mode of collection of information for health facilities was collated by the method of personal interaction with the concerned officials, physical inspection and recording from relevant registers. Coverage The Facility Survey covered a total of 47 Health facilities from 70 districts in Uttar Pradesh. The number of health care establishments covered from all the 70 districts is 2595 Sub Health Centre, 51 PHCs, 920 CHCs, sub- divisional hospitals and 2 District Hospitals. 19

20 5. DEMOGRAPHIC BACKGROUND OF UTTAR PRADESH Geographically the state can broadly be divided into four divisions, namely: Western (Paschim Pradesh): Meerut, Bulandshahr, Gautam Buddha Nagar, Ghaziabad, Baghpat, Saharanpur, Muzaffar Nagar, Moradabad, Bijnor, Rampur, Bareilly, Budaun, Pilibhit, Shahjahanpur, Agra, Firozabad, Mainpuri, Mathura, Aligarh, Etah, Jyotiba Phule Nagar, Mahamaya Nagar, Kanshiram Nagar. Central (Avadh Pradesh): Kheri, Farrukhabad, Hardoi, Kannauj, Etawah, Auraiya, Kanpur Dehat, Kanpur Nagar, Unnao, Rae Bareli, Bara Banki, Lucknow, Sitapur. Bundelkhand: Jalaun, Hamirpur, Jhansi, Mahoba, Lalitpur, Banda, Chitrakoot. Eastern (Purvanchal Pradesh): Fatehpur, Kaushambi, Allahabad, Mirzapur, Sonbhadra, Chandauli, Ghazipur, Ballia, Varanasi, Sant Ravidas Nagar, Jaunpur, Pratapgarh, Sultanpur, Azamgarh, Mau, Deoria, Kushinagar Maharajganj, Sant Kabir Nagar, Gorakhpur, Ambedkar Nagar, Faizabad, Basti, Gonda, Siddharth Nagar, Balrampur, Sravasti, Bahraich. The basic demographic indicators of the state of Uttar Pradesh and its districts as of Census 21 are shown in Table 1; the population of the state in 21 is enumerated as 4 million. The decadal growth rate of the state during is 20.2 per cent. Decadal growth rate of above 20 per cent was recorded in the districts of Moradabad, Rampur, Jyotiba Phule Nagar, Ghaziabad, Gautam Budha Nagar, Aligarh, Mathura, Bareilly, Shahjahanpur, Kheri, Sitapur, Lucknow, Lalitpur, Chitrakoot, Kaushambi, Bara Banki, Baharaich, Sravasti, Balrampur, Gonda, Siddharth Nagar, Maharajganj, Kushinagar and Sonbhadra. The sex ratio of the state is 9 females per males, the lowest (851) in Gautam Budha Nagar and highest (1,4) in Jaunpur. The overall literacy rate is 67.7 per cent, 77.3 per cent for males and 57.2 per cent for female. 20

21 TABLE 1 BASIC DEMOGRAPHIC INDICATORS Basic demographic indicators of Uttar Pradesh and its districts, Census 21, India State/Districts Population Percentage decadal Percentage literate 7+ (in thousands) growth rate 1 Sex ratio 2 Male Female Total Saharanpur 3,466, Muzaffar Nagar 4,3, Bijnor 3,682, Moradabad 4,772, Rampur 2,335, Jyotiba Phule Nagar 1,840, Meerut 3,443, Baghpat,, Ghaziabad 4,681, Gautam Buddha Nagar 1,648, Bulandshahr 3,499, Aligarh 3,673, Mahamaya Nagar 1,564, Mathura 2,547, Agra 4,4, Firozabad 2,498, Etah 1,774, Mainpuri 1,868, Budaun 3,681, Bareilly 4,448, Pilibhit 2,1, Shahjahanpur 3,6, Kheri 4,1, Sitapur 4,483, Hardoi 4,2, Unnao 3,1, Lucknow 4,589, Rae Bareli 3,4, Farrukhabad 1,885, Kannauj 1,656, Etawah 1,581, Auraiya 1,379, Kanpur Dehat 1,796, Kanpur Nagar 4,581, Jalaun 1,689, Jhansi 1,998,

22 Lalitpur 1,221, Hamirpur Mahoba 1,4, ,958 Banda 1,799, Chitrakoot 991, Fatehpur 2,632, Pratapgarh 3,2, Kaushambi 1,599, Allahabad 5,954, Bara Banki 3,260, Faizabad 2,470, Ambedkar Nagar Sultanpur 2,397,888 3,797, Bahraich 3,487, Sravasti 1,7, Balrampur 2,8, Gonda 3,433, Siddharth Nagar 2,559, Basti 2,464, Sant Kabir Nagar 1,7, Maharajganj 2,684, Gorakhpur 4,440, Kushinagar 3,564, Deoria 3,1, , Azamgarh 4,6,9.1 1, Mau 2,2, Ballia 3,239, Jaunpur 4,494,2.9 1, Ghazipur 3,620, Chandauli 1,952, Varanasi 3,676, Sant Ravidas Nagar (Bhadohi) 1,578, Mirzapur 2,496, Sonbhadra 1,862, Kanshiram Nagar 1,436, UTTAR PRADESH 199,8, Source: Primary Census Abstract, Series 20, Census of India, Females per 1,0 males. 22

23 6. SUB HEALTH CENTRE Introduction Sub-Health Centres (SHCs) are the most peripheral health institutions catering to the health care needs of the rural population. It is the most peripheral contact point between the Primary Health Care system and the community. It is manned by one multipurpose worker (male) and one multi-purpose worker (female) /ANM. Even though the sub-centre wise population norm at the national level has been met, there are wide intra-state variations. Under the Facility Survey during 22-, a total 2595 SHCs were surveyed from 70 districts in Uttar Pradesh. This chapter presents the findings from surveyed sub-health Centres. Population covered by Sub-Health Centres Out of the 2595 Sub-Health Centres, average population covered by a SHC is 8,527. The highest average population covered (,281) among the surveyed SHCs is in Sant Ravidas Nagar Bhadohi district and the lowest (4,599) in Kanpur Nagar district being slightly lower than prescribed government norms (table 1.1). Infrastructure (Table 1.2) Own building Eighty one per cent of SHCs have their own government building. All 61 and 23 surveyed SHCs in Auraiya and Lalitpur districts are having own government building; Out of 79 surveyed SHCs in Kannauj district only 98 per cent of the SHCs are having their own government building. More than 90 of the surveyed SHCs in Muzaffar Nagar, Rampur, Jyotiba Phule Nagar, Meerut, Baghpat, Mainpuri, Pilibhit, Shahjahanpur, Sitapur, Farrukhabad, Jalaun, Jhansi, Hamirpur, Banda, Pratapgarh, Bara Banki, Faizabad, Sravasti, Balrampur, Kushinagar, Deoria, Varanasi and Mirzapur are functioning from government building (table 1.2). Water supply At the state level, proportion of SHCs housed in government buildings, which are getting water supply through piped, bore well, hand pump or any other sources is 81.2 per cent. The lowest water supply (44.1 per cent) is noted in Mau districts. Water supplies at surveyed Sub Health Centres are below the state average in 33 districts namely Meerut, Aligarh, Hathras, Mathura, Kheri, Sitapur, Hardoi, Unnao, Lucknow, Jhansi, Lalitpur, Chitrakoot, Fatehpur, Kaushambi, Bara Banki, Ambedkar Nagar, Sultanpur, Sravasti, Balrampur, Siddharth Nagar, Basti, Sant Kabir Nagar, Maharajganj, Kushinagar, Azamgarh, Deoria,, Ballia, Jaunpur, Ghazipur, Varanasi, Sant Ravidas Nagar, Mirzapur and Bhadohi. 23

24 Electricity Only five per cent of the SHCs, functioning from government buildings in Uttar Pradesh, are having regular electricity facility. The situation in Moradabad, Jyotiba Phule Nagar, Ghaziabad, Bulandshahr, Aligarh, Hathras, Mathura, Agra, Firozabad, Bareilly, Pilibhit, Shahjahanpur, Kheri, Sitapur, Hardoi, Unnao, Lucknow, Kanpur Dehat, Jalaun, Hamirpur, Chitrakoot, Kaushambi, Bara Banki, Sultanpur, Sravasti, Balrampur, Gonda, Siddharth Nagar, Basti, Sant Kabir, Maharajganj, Kushinagar, Azamgarh, Deoria, Ghazipur, Sant Ravidas Nagar Bhadohi and Sonbhadra districts is serious where zero per cent of the SHCs have a regular supply of electricity.(table1.2) Toilet facility The Facility Survey also collected information on the availability of toilets facilities in the SHCs. Nearly one fourth of the surveyed SHCs did not have toilet facility in the state. More than Ninety per cent of SHCs have a toilet facility in Bijnor, Moradabad, Firozabad, Farrukhabad, Kannauj and Auraiya. But only 35 per cent of the SHCs in Sultanpur have toilet facility, which is almost 39 per cent less than the state average (table 1.2). Staff at Sub Health Centres The information on health workers of SHCs by sex was collected for both sanctioned posts and filled posts. The same information is presented in Table 1.3. The per cent in position is taken from the total sanctioned posts of SHCs in each district. The role of female health worker is very important at SHCs. Almost 95 per cent of the surveyed Sub Health Centres are having ANM in position. Out of 70 districts, 28 districts namely Muzaffar nagar, Moradabad, Jyotiba Phule Nagar, Aligarh, Hathras, Mainpuri, Shahjahanpur, Sitapur, Hardoi, Farrukhabad, Auraiya, Kanpur Dehat, Lalitpur, Chitrakoot, Pratapgarh, Allahabad, Faizabad, Ambedkar Nagar, Sultanpur, Sravasti, Gonda, Siddharth Nagar, Basti, Gorakhpur, Mau, Ballia, Ghazipur and Mirzapur have 1 per cent SHCs with ANM in position. Along with this, 9.2 per cent of the SHCs in the state are having additional ANMs in position. It is highest (59 per cent of the SHCs) in Sravasti district having addition ANM while Azamgarh, Deoria, Gonda, Kanpur Dehat, Kanpur Nagar, Lucknow, Mainpuri, Firozabad, Mathura, Hathras, Aligarh, Meerut, Moradabad and Saharanpur do not having additional ANMs at Surveyed Sub Health Centres. The proportion of SHCs with at least one male health worker varies from 2 per cent in Baghpat to per cent in Budaun. Not even single surveyed SHCs in Saharanpur, Muzaffar nagar, Bijnor, Moradabad, Rampur, Jyotiba Phule Nagar, Meerut, Ghaziabad, Gautam Buddha Nagar, Bulandshahr, Aligarh, Hathras, Mathura, Firozabad, Etah, Mainpuri, Bareilly, Pilibhit, Kheri, Hardoi, Lucknow, Farrukhabad, Auraiya, Kanpur Dehat, Kanpur Nagar, Banda, Chitrakoot, Pratapgarh, Allahabad, 24

25 Bara Banki, Faizabad, Sultanpur, Bahraich, Sravasti, Balrampur, Siddharth Nagar, Gonda, Basti, Sant Kabir Nagar, Maharajganj, Azamgarh, Deoria,, Jaunpur, Varanasi and Sonbhadra districts having Male health workers in position. In the state as a whole, only 1.9 per cent of the SHCs are having male health worker in position. Other services Citizen Charter displayed at SHC This charter is the framework for users to know about the availability of the services, Quality of the services, Standard of services and other general information. Every Health Facility is supposed to display it. 25

26 As per the government norms, each SHC should have citizen charter displayed in local language at the front entrance of the SHC so people can see and understand about SHC functioning. Out of the surveyed SHCs, 33 per cent of the SHCs have displayed Citizens Charter (remaining 67 per cent of the SHCs do not have this facility). It ranges from 7 per cent in Aligarh to 73 per cent Etawah district (figure 1(a), 1(b) &1(c)). VHSC (Village Health and Sanitation Committee): At village level, Village Health and Sanitation Committees have been constituted. Their roles and responsibilities are to facilitate and monitor the functioning of Sub health-centres. The proportion of SHCs where the VHSC facilitated, though not in the SHC village, 69 per cent Kushinagar and Moradabad, Jyotiba Phule Nagar, Meerut, Baghpat, Ghaziabad, Aligarh, Hathras, Mathura, Firozabad, Etah, Mainpuri, Hardoi, Farrukhabad, Auraiya, Allahabad, Bahraich, Sravasti, Gonda, Azamgarh, Mau, Jaunpur, Ghazipur, Varanasi, Sant Ravidas Nagar, Bhadohi and Sonbhadra having 1 per cent. Out of 2595 surveyed SHCs, 95 per cent of the SHCs were facilitated by VHSC in their SHC village or SHC area (figure 2(a), 2(b) & 2(c)). 26

27 27

28 Untied fund received in the previous financial year Under NRHM, every facility (SHC, PHC, CHC, and DH) is supposed to get a fixed amount of money as untied fund, which they can use for various purposes, e.g. Sub Health-Centre gets a fixed amount of Rs.,0 per annum, PHC gets a fixed amount of Rs 25,0 per annual; CHC gets a fixed amount of Rs, 50,0 per annual, District Hospital get an amount of Rs, 5,,0 per annum. 28

29 The information collected about untied fund from each surveyed SHC during the facility survey and it is calculated from those SHCs where they received untied fund for previous financial year. Almost all the SHCs have received untied fund but when it comes to utilization of the fund, it varies from district to district. Sixty eight per cent of the SHCs have utilized untied fund for various purpose. The lowest utilization of untied fund 35 per cent was in Ballia district and highest 94 per cent in Rampur district. 7. PRIMARY HEALTH CENTRE Introduction Primary Health Centres (PHCs) have a major responsibility of providing both preventive and curative health care services in the area. This includes delivery of reproductive and child health services, such as antenatal care and immunization in addition to routine in-patient and out-patient services. PHCs are accessible to a larger population, as one PHC is expected to serve 30,0 populations. However, just the availability of PHCs is not sufficient for effective delivery of these services. They should also have essential infrastructure, staff, equipment and supplies. This chapter presents the status of the 51 PHCs surveyed in Uttar Pradesh State with respect to the availability of selected infrastructure, staff and services provided by the PHCs. Staff Position Only selected staff is given in Table 2.1. At least one Medical Officer is available in 73.6 per cent of the surveyed PHCs, which includes 6.6 per cent having a Lady Medical Officer (LMO). Medical Officer (AYUSH) posted in 25.5 per cent of the PHCs. Eight four per cent of the PHCs were having Pharmacist in position. Medical Officer The availability of at least one Medical Officer (MO) at the PHC is absolutely essential. In Pilibhit, Shahjahanpur, Unnao, Lucknow, Kanpur Dehat, Allahabad, Maharajganj and Varanasi every PHC has Medical Officer. In case of Etah, only 25 per cent of the PHCs have a Medical Officer in position. Lady Medical Officer The inclusion of a Lady Medical Officer on the PHC staff is advantageous for maternal care services, as women can confide with lady doctors more easily. However, only 6.6 per cent of the PHCs have at least one Lady Medical Officer in Uttar Pradesh. It is the highest in Unnao where 30 per cent of the PHCs (with at least one Medical Officer) have a Lady Medical Officer. In Muzaffar nagar, Bijnor, Aligarh, Hathras, Firozabad, Etah, Mainpuri, Budaun, Pilibhit, Shahjahanpur, Kheri, Hardoi, Lucknow, Rae Bareli, Farrukhabad, Kannauj, 29

30 Etawah, Auraiya, Jalaun, Mahoba, Banda, Chitrakoot, Fatehpur, Pratapgarh, Allahabad, Faizabad, Ambedkar Nagar, Sultanpur, Bahraich, Sravasti, Balrampur, Gonda, Siddharth Nagar, Basti, Sant Kabir Nagar, Gorakhpur, Azamgarh, Mau, Ballia, Jaunpur, Varanasi and Sonbhadra districts, not even a single PHC have one lady Medical Officer. Medical Officer (AYUSH) AYUSH stands for Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy. One of the NRHM objectives is to revitalize local health traditions and mainstream the AYUSH into the public health care system. Presence of Medical Officer (AYUSH) was reported in 25.5 per cent of the PHCs. Out of 70 districts, only nine districts (Saharanpur, Jyotiba Phule Nagar, Firozabad, Badaun, Pilibhit, Kannauj, Hamirpur, Fatehpur, Allahabad and Sultanpur) has no AYUSH doctor. Pharmacist It is important to have a Pharmacist at PHCs for drug storage and drug dispensing. Eighty four per cent of the PHCs were having Pharmacist in position. Compared to other districts of the state, Lalitpur has lowest (42 per cent) percentage of pharmacists in position. 30

31 INFRASTRUCTURE Table 2.2 presents the percentage of PHCs with selected infrastructural facilities such as own building, functioning of PHCs on 24 7, continuous power supply, functional vehicle and beds for in-patients in each district. In Uttar Pradesh, out of 51 surveyed PHCs, 27.2 per cent are functioning on 24 hours basis. Ten per cent of the PHCs have regular electricity supply. Functional vehicles are not very common, with only per cent of PHCs having functional vehicle. In 45 per cent of the PHCs, not even one bed is available. Residential Quarter for Medical Officer For attending to emergency cases round the clock, it is necessary to have a Medical Officer staying in the PHC compound. But this is determined by the availability of staff quarters as well as the desire of doctors to stay in the quarters. Table.2.2 shows that in the state as whole; almost 25 per cent of the PHCs have no residential quarters for the MOs. In seven districts namely Meerut, Hathras, Pilibhit, Shahjahanpur, Sitapur, Jalaun and Mahoba, all surveyed PHCs have residential quarters for Medical Officers (table 2.2) PHCs functioning 24 7 Out of the 70 districts, there were no districts where all the surveyed PHCs were functioning on 24 7 hours basis. In Deoria 85 per cent PHCs were operating on 24x7 basis, while in Farrukhabad, Etawah, Kanpur Dehat, Jalaun, Banda, Fatehpur and Siddharth Nagar; no PHCs are functioning on 24x7 basis (table 2.2). Regular Power supply of Electricity Electricity is important at PHC level because failure of electricity or not having backup of generator may interrupt the day-to-day functioning as well as emergency services at PHCs. There are certain divisions without power, health personnel or doctors cannot perform their duty such as delivery, major/ minor operations. Ninety per cent of the PHCs in Uttar Pradesh function without electricity/ no regular power supply. In Meerut, it is reported that 46 per cent of the PHCs have regular power supply. Followed by 33 per cent in Baghpat and 31 per cent in Etah and Mainpuri. Functional Vehicle In the context of the out-reach programme of the PHCs and referral of complicated cases to higher health facilities, availability of a vehicle in running condition becomes a critical input. But only per cent of the surveyed PHCs in Uttar Pradesh have a functional vehicle. Twenty three districts namely Bijnor, Rampur, Meerut, Aligarh, Hathras, Kanpur Dehat, Kanpur Nagar, Jalaun, Lalitpur, Mahoba, Fatehpur, Bahraich, Sravasti, Sant Kabir Nagar, Maharajganj, Kushinagar, Mau, Ballia, Jaunpur, Chandauli, and Sonbhadra; where not even a single vehicle was functional or on road in the surveyed PHCs. 31

32 Availability of Beds at PHCs According to government norms, each PHC needs to have 4-6 indoor beds for patients covering 20,0 to 30,0 populations. Figure 5 shows progress of PHCs having at least 4 beds from DLHS-3 to DLHS-4. Referral services available at PHC Out of the 1,1 surveyed PHCs in the state and those functioning on 24 7 hours basis, 23.7 per cent have the facility of referral services especially for pregnancy/ deliveries. This information was also collected during the facility survey of DLHS-3. Figure 6 shows alarming decline in case of referral services for pregnancies and deliveries at PHC level. It shows almost per cent decrease from DLHS-3 to DLHS-4. 32

33 New born care services This information was collected in the facility survey with a reference period of last one month prior to the survey. In case of new born care services, information was collected in terms of availability of services at PHC. Nearly 85 per cent of the PHCs have provided new born care services during the last month. The PHCs in districts namely Gautam Buddha Nagar, Farrukhabad, Allahabad and Ballia have not provided any new born care services during the last one month. Deliveries conducted at PHC This information was collected in the facility survey with a reference period of last one month prior to the survey. Figure 7 clearly shows that the performance of the PHCs has improved. The PHCs in districts of Saharanpur, Moradabad, Jyotiba Phule Nagar, Gautam Buddha Nagar, Bulandshahr, Aligarh, Hathras, Firozabad, Etah, Mainpuri, Pilibhit, Shahjahanpur, Unnao, Rae Bareli, Farrukhabad, Auraiya, Jhansi, Pratapgarh, Allahabad, Ambedkar Nagar, Sultanpur, Bahraich, Sravasti, Ballia, and Ghazipur have not performed even a single delivery in the last one month prior to the survey. Among those districts where PHCs have provided services for conducting deliveries, the lowest ( per cent) of the PHCs in Mau district have conducted at least deliveries (Table 2.3). 33

34 Citizens Charter displayed at PHC This charter is the framework for the users to know about the availability of the services in PHCs, quality and standard of services and other general information. Every health facility is supposed to display it. Out of the surveyed PHCs, 38 per cent of them have displayed Citizens Charter and 62 per cent of the PHCs still do not have this facility at PHCs. It ranges from 6 per cent in Siddharth Nagar to 80 per cent in Etawah and Unnao districts (table2.4). Rogi Kalyan Samiti (RKS) constituted The main objective of RKS is creation of a better atmosphere, Orientation and incentives for staff and proper management of resources. The proportion of PHCs where the RKS has been constituted is more than 31 per cent in all the districts of Uttar Pradesh, except in Hathras and Etah (zero per cent) (table 2.4). Untied Fund received Under NRHM, every PHC is supposed to get a fixed untied amount of money, which they can use for various purposes, e.g. a fixed amount of Rs 25,0 per annum. Information was collected about untied fund from each surveyed PHC and it is calculated from those PHCs where they received untied fund for previous financial year. Ninety one per cent of the PHCs have received untied fund. It is observed that 1 per cent of the PHCs have utilized the untied fund received (table 2.4). 8. COMMUNITY HEALTH CENTRE Introduction Though not designated as such, Community Health Centres (CHCs) are also first referral units where referral cases from lower level health care establishments are sent. The CHCs have to take care of these cases besides their usual health care activities. There are 920 CHCs in Uttar Pradesh, including Block PHCs. Staff Position The availability of specialist physicians in the CHCs is much below the prescribed standard. A gynaecologist/obstetrician is available in just per cent of the CHCs in DLHS-4. Paediatrician is available in about percent of CHCs. Out of 920 surveyed CHCs only per cent of the CHCs have Anaesthetist and one-tenth of the CHCs are having Public Health Manager in Position. Obstetrician/Gynaecologist Availability of at least one gynaecologist/obstetrician at the CHCs is nil in some of the districts (Muzaffar nagar, Bijnor, Moradabad, Jyotiba Phule Nagar, Aligarh, Kheri, Kannauj, Auraiya, Jalaun, Banda, Chitrakoot, Jhansi, Bahraich, Gonda, Siddhartha Nagar, Basti, Ballia, and Sonbhadra), while in remaining districts also 34

35 the situation is not that much satisfactory. If we see the status of districts, out of CHCs surveyed in Bara Banki district only 9 CHCs were having Obstetrician/Gynaecologist in position at the time of survey. 2 out of 920 CHCs have Obstetrician/ Gynaecologist available (Table 3.1). Paediatrician The presence of one paediatrician in per cent of the CHCs is far from satisfactory. There is no paediatrician in the CHCs in Hathras, Firozabad, Jalaun, Chitrakoot, Kaushambi, Bahraich, Balrampur, Gonda and Basti districts. In Lucknow, out of 8 CHCs, 5 CHCs were having paediatrician (Table 3.1). Anaesthetist The situation of posting Anaesthetist is not very good in Uttar Pradesh. In 89 per cent of the districts do not have even single Anaesthetist at CHC. More or less the same situation was observed in all the districts of Uttar Pradesh for the position of Public Health Manager (Table 3.1). Infrastructure Functional Operation Theatre Out of 920 surveyed CHCs, more than half of the CHCs were having functional Operation Theatres at the time of survey. The Operation Theatre has been treated as functional in case of surgeries are carried out in the operation theatre during the last one month (Table 3.2). CHCs designated as FRU If some of the complications of pregnancy such as anaemia, haemorrhage, obstructed labour, sepsis are detected early and managed appropriately, maternal morbidity and mortality can be reduced substantially. But PHCs are not in a position to give complete obstetric care to the patients due to limited facilities and expertise available. Hence, CHCs have been identified by the government as First Referral Units (FRUs) and have been supplied with necessary equipment and kits to enable them to meet any emergency related to the health care of the mother, particularly emergency obstetric care (EmOC). It is clearly seen from the table 3.2 that only about per cent of the CHCs in Uttar Pradesh are functioning as first referral units. Available services at CHCs Out of 920 surveyed CHCs, 99 per cent of the CHCs have 24 7 hours normal delivery services in the state. As compared to DLHS-3, 7 per cent more CHCs have these services in DLHS-4. 35

36 New born care services Nearly two-thirds of the CHCs have new born care services where during the last one month prior to the survey they have provided services for new born care on 24 7 hour basis. From figure 9, one can see a nearly percent increase from DLHS-3 to DLHS-4. 36